What is the recommended treatment for urinary tract infections (UTIs) in males according to the Infectious Diseases Society of America (IDSA) guidelines?

Treatment of Urinary Tract Infections in Males

For afebrile men with uncomplicated UTI, treat with ciprofloxacin or trimethoprim-sulfamethoxazole for 7 days; for febrile UTI or when prostatitis cannot be excluded, treat for 14 days. 1, 2, 3, 4

Classification and Diagnostic Requirements

• All UTIs in males are classified as complicated UTIs, requiring urine culture and susceptibility testing before initiating therapy 1, 2
• The microbial spectrum is broader than in women, including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 1, 2
• Antimicrobial resistance rates are higher in male UTIs compared to uncomplicated female UTIs 2
• Evaluate for underlying urological abnormalities or complicating factors that may require separate management 1

Treatment Duration Algorithm

For Afebrile Men Without Complicating Conditions:

• Treat for 7 days with either ciprofloxacin or trimethoprim-sulfamethoxazole 3, 5
• A landmark 2021 JAMA trial demonstrated noninferiority of 7-day treatment compared to 14-day treatment in afebrile men (93.1% vs 90.2% symptom resolution), with no difference in recurrence rates (9.9% vs 12.9%) 3
• Shorter duration reduces adverse events (20.6% vs 24.3% with longer treatment) 3

For Febrile Men or When Prostatitis Cannot Be Excluded:

• Treat for 14 days 1, 2, 4
• A 2023 multicenter French trial definitively showed that 7-day treatment was inferior to 14-day treatment for febrile UTI in men (55.7% vs 77.6% treatment success), establishing that shorter courses should not be used in this population 4
• This represents the most recent high-quality evidence specifically addressing febrile UTI in men 4

Empiric Antibiotic Selection

First-Line Options for Systemic Symptoms:

• Amoxicillin plus an aminoglycoside 1, 2
• Second-generation cephalosporin plus an aminoglycoside 1, 2
• Intravenous third-generation cephalosporin 1, 2

Oral Therapy Considerations:

• Fluoroquinolones (ciprofloxacin or ofloxacin) may be used only when local resistance rates are <10% 1, 2
• Do not use fluoroquinolones if the patient has used them in the last 6 months or is from a urology department 1, 2
• Trimethoprim-sulfamethoxazole is an alternative oral option when susceptibility allows 3

Critical Pitfalls to Avoid

• Never treat febrile UTI or suspected prostatitis for only 7 days - this is definitively inferior based on the 2023 trial showing a 22% absolute difference in treatment success 4
• Do not use fluoroquinolones empirically in areas with resistance rates >10% 1, 2
• Do not fail to obtain urine culture before starting antibiotics 1, 2
• Do not assume all male UTIs require 14 days - afebrile men without complications can be treated for 7 days 3, 5
• Do not overlook underlying structural or functional urinary tract abnormalities that require separate management 1, 2

Special Situations

Catheter-Associated UTI:

• Remove or change the catheter when possible 2
• Follow the same duration guidelines based on fever status 2

Patients Requiring Hospitalization:

• Start with parenteral therapy until clinical improvement 2
• Transition to oral therapy when hemodynamically stable and afebrile for at least 48 hours 1, 2

Follow-Up Management

• Tailor therapy based on culture results once available 2
• Monitor for symptom resolution and consider follow-up urine culture in complicated cases 1
• Consider imaging studies if recurrent infections occur to rule out anatomical abnormalities 2
• Address any identified underlying urological abnormalities to prevent recurrence 1, 2